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European Journal of Endocrinology 10.1530/EJE-16-0616 imbalance betweenexcessiveformationofoxidants Hence, oxidativestresswasintroducedtodefinethe and nucleicacids;compromisecellviability( interrupt oxidativeequilibrium;damageproteins, unfavorable cellularconditions,oxygenderivativescan Living organismscannotexistwithoutoxygen;yetunder gradually highlightedasanintegralpartofaerobiclife( Oxidative metabolismandredoxhomeostasishavebeen Introduction active mediatorofvariousmetabolicandreproductivedisorders. background, canpotentiallycompromisenormalmetabolicandreproductivefunctionsinwomenmayact as an account, nutritionanditsaccompanyingpostprandialoxidativestress,intheuniquecontextoffemalehormonal violate delicateoxidativebalancethatismandatorytosecurenormalreproductivefunction.Taken alltheaboveinto secretion takeplace.Simultaneously, inreproductivetissues,nutrition-inducedoxidativestresscanpotentially subclinical inflammation,endothelialdysfunction,mitochondrialderegulationandimpairedinsulinresponse and orchestrated inthemainmetabolicorgans,includingadiposetissue,skeletalmuscle,liverandpancreas,where in thepostprandialstate,alteringmetabolicstateoftissues.Adominounfavorablechangesis hormonal balance.Nutrientingestionpromotesamajorinflammatoryandoxidativeresponseatthecellularlevel Nutrition cangenerateoxidativestressandtriggeracascadeofmoleculareventsthatdisrupt Abstract Unit, 3rdDepartmentofInternalMedicine,UniversityAthensMedicalSchool,Athens,Greece 1 Georgia Kassi Evanthia Diamanti-Kandarakis metabolic andreproductive disorders inwomen Nutrition asamediatorofoxidativestress in MECHANISMS INENDOCRINOLOGY Department ofEndocrinologyandDiabetesCenterExcellence,EUROCLINIC,Athens,Greece DOI: 10.1530/EJE-16-0616 www.eje-online.orgwww.eje-online.org aspects ofmetabolicandreproductive abnormalitiesinpolycysticovariansyndrome. Greece. Her research interests havefocused for the last 25years on clinical, molecular and environmental the ChairmanofDepartment ofEndocrinologyandDiabetesCenterExcellence,EUROCLINIC, Athens, Dr EvanthiaDiamanti-Kandarakis Invited Author’s profile Review

2 © 2017EuropeanSocietyof Endocrinology © 2016EuropeanSociety ofEndocrinology 1 and others E Diamanti-Kandarakis , Olga Papalou isaProfessorofInternalMedicine–EndocrinologyandMetabolism and Printed inGreatBritain 1 , EleniA Kandaraki

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stress. Macronutrients can be inflammatory and possibly andpossibly stress. Macronutrientscanbeinflammatory body, suchasnutrition,canpotentiallygenerate oxidative physiological conditions,normalfunctionsofhuman plethora ofhumandiseases( oxidative stressliesinthepathophysiologicalcoreof a body( in thepresenceoflimitedantioxidantdefenses Nutrition andoxidativestress Published byBioscientifica Ltd. There is an increasing body of evidence showing that There isanincreasingbodyofevidenceshowingthat 2 and 3 ). 2 Endocrine Downloaded fromBioscientifica.com at09/26/202101:56:54AM 4 , 5 , (2017) Endocrinology European Journal of gmail.com e. Email to EDiamanti-Kandarakis should beaddressed Correspondence 6 176 diamanti.kandarakis@ ). However, evenunder 176 : 2 176 :2 , R79–R99

R79 –R99 via freeaccess European Journal of Endocrinology www.eje-online.org ( adenine dinucleotideandflavinmononucleotide(FMN) of catalyticcofactors,(BH4),flavin of nitricoxidesynthase (NOS) and under thepresence is synthesizedfrom derive fromnitricoxide(NO)( generating eventuallysuperoxide(O a tendencyforanelectrontodirectlypassoxygen, mitochondrial electrontransportchain(ETC),thereis to betheprincipalsource ofROS.Specifically, inthe ( activation takesplaceviadifferentcellularprocesses singlet oxygenandhydrogenperoxide(H anion(O formed uponincompletereactionofoxygen,including species (RNS).ROSderivefrommolecularoxygen, reactive oxygenspecies(ROS)andnitrogen There are two main classes of free radicals or oxidants: oxidative Elements offundamentals of variousmetabolicandreproductivedisturbances( and thereforecouldbeinvolvedinthepathophysiology subclinical inflammationandendothelialdysfunction Postprandial oxidativestresshasbeencloselylinkedto of excessorinadequatesupplywithnutrients( load andtheantioxidantdefenseasaconsequence postprandial state of imbalance between the pro-oxidant oxidative stress – has been introduced to describe the pro-oxidant ( 15 i. 1 Fig. Review ). Undercertainstimuli,NOreactswithsuperoxide RNS areafamilyofchemicalcompoundsthat ) ( 12 ). However, mitochondriaareconsidered 7 ). A new term – nutritional or postprandial ). Anewterm–nutritionalorpostprandial l -arginine, viathecatalyticaction 2 − ), hydroxylradical(OH 14 and others E Diamanti-Kandarakis ). Physiologically, NO 2 − ) (

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8 ). ). oxidase ( ROS generation, as well as to the activation of NADPH (RAGE) activatesNF- multiligand receptorforadvancedglycationendproducts via multiplemechanisms( their formation,AGEspromoteROSandRNS as well as from absorbed exogenous sources ( endogenous nonenzymaticglycationofmacromolecules, group ofmorethan20differentcompounds,derivedfrom AGEs. AGEs,orglycotoxins,constituteaheterogenous properties are share truly pro-oxidant and inflammatory other moleculesthathavealsobeenacknowledgedto trioxide (N of RNS,suchasnitrogendioxide(·NO and canfurtherpromotetheproductionofotherforms to be one of the most toxic RNS produced in human body (O system ofthebody, oxidative stressdominates ( compensated bythepowerfulantioxidantdefense pro-oxidants ( ,selenium(Se)andzinc(Zn),usedtoterminate such asglutathione,,vitaminC,A, areexogenousandendogenousmolecules, peroxidase(GPx)( including (SOD), (CAT) and key enzymesthatcandetoxifyexcessiveROSandRNS, nonenzymatic. Enzymaticantioxidantsconstituteinnate, be dividedintotwomajorcategories:enzymaticand to maintainoxidativeequilibrium( Nutrition andoxidativestress 2 − Antioxidants aretheopposingforce ofhumanbody In addition to the above mentioned pro-oxidants, When overproduction of free radicals cannot be ) generatingperoxynitrite(ONOO 19 2 , O 20 3 13 ) ( ). 16 , 23 ONOO superoxide anion;OH species; ROS,reactiveoxygen O ;RNS,reactivenitrogen adenine dinucleotidephosphate; NO, ;NADPH,nicotinamide GSSG, glutathionedisulfide;H mononucleotide; GSH,glutathione; flavin adeninedinucleotide;FMN, endothelial nitricoxidesynthase;FAD, (BH4, tetrahydrobiopterin; ENOS, different enzymaticreactions production andclearancevia Molecular pathwaysofROSandRNS Figure 1 ). ). κ B, whichinturnleadstoincreased Downloaded fromBioscientifica.com at09/26/202101:56:54AM − , ). 18 ). BindingofAGEstotheir 22 ), whereasnonenzymatic Fig. 2 176 − − ), whichisbelieved , hydroxylradical; 2 :2 ) anddinitrogen ) ( 21

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R80 ) and 2 via freeaccess − : European Journal of Endocrinology ROS, reactiveoxygenspecies;RSNO,S-nitrosothiol). ; ONOO peroxide; NO (AGEs, advancedglycationendproducts;H complementary, interconnectedandgiverisetoeachother human body, astheseoppositeforcesareactually Pro-oxidants andantioxidantsrepresentthe‘yinyang’of Figure 2 environmental stimuli, there is an increasing share of that earlylifedevelopment iscriticallysensitiveto of healthanddiseases’hypothesis, whichpostulates Since theestablishmentof the‘Developmentalorigins Nutrition triggersoxidativestress earlyinlife oxidative stress Nutrition isamajormodulatorof oxidative stressandalterbody’s ( for thehumanbodythatcanpostprandiallytrigger andpro-oxidant stimuli themselves canbeinflammatory ( between caloricintakeandlow-gradeinflammation Since theestablishmentofbidirectionalassociation physiological functionsofhumanbody, suchasnutrition. variety ofdiseases( of oxidativestressnotonlyinthepathophysiologya pathways has led scientific society to investigate the role This activeimplicationofROSinmultiplemolecular ROS initiatemultiplemolecularpathways( 32 Review ), a crucial query emerged whether macronutrients ), a crucial query − , nitroxyl;O − , peroxynitrite;RNS,reactivenitrogenspecies; 5 , 27 2 , − 28 , superoxideanion;OH , 29 , 30 and others E Diamanti-Kandarakis , 31 ) butalsoinnormal 2 O 2 , hydrogen

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). gestation, but not during postweaning period ( malnutrition, obesityorobesogenicmaternaldietduring through variousexperimentalmodels( mediator ofnutrition-inducedepigeneticchanges compromised fertilitylaterinlife( at anincreasedriskforcardiometabolicdisordersand context ofaprenatallyrichnutritionalenvironmentare adulthood ( cardiovascular diseaseandreproductivedysregulationin linked toincreasedriskforobesity, insulinresistance, with earlycatch-upgrowthduringinfancyhasbeen undernutrition has been extensively studied ( promoter oftheseintrauterineepigeneticmodifications health anddisease. during earlyhumandevelopmentcanaffecttheriskfor literature focusingonhowenvironmentalfactorsacting evaluating arealmixedmeal inhealthysubjects,acute comparison withglucoseand lipids( oxidative ROSformationbut toamuchlesserextentin persistent, whereasprotein (cysein) intakealsoincreased to thatofglucoseingestion butmoreprolongedand ROS generationbyleukocytes,similarinmagnitude ingestion ofsaturatedfat(cream)ledtoanincrease in andproteinintakewerealsopublished.Acute intake bynormalsubjects( mononuclear (MNC)leukocyteswasafterglucose ROS generationbypolymorphonuclear(PMN)and that amacronutrientinducesinflammationand byMohanty The initialobservation Nutrition andoxidativestress atthecellularlevel disorders inadulthood. evolving riskfactorformetabolicaswellreproductive pathways, including generation of oxidative stress, an development caninduceepigeneticchanges,viadifferent during thecriticalperiodsofprenatalandperinatal definitive conclusionsbeestablished.However, nutrition experimental models,andthereisalongwayuntil domain ofdevelopmentalprogrammingoriginatesfrom their offspring( accompanied byasignificantattenuationofadiposityin Simultaneously, supplementation was making themvulnerabletodiabetogeniceffects( and impairedantioxidantcapacityintheoffspring, was associatedwithincreased oxidative stressmarkers Nutrition andoxidativestress Oxidative stress hasbeen proposed as a potential Among environmentalfactors,nutritionasapotent Currently, themajorityofevidenceregarding 35 , 44 in utero 36 ). , 37 ). Likewise,offspringraisedinthe andlowbirthweight,combined Downloaded fromBioscientifica.com at09/26/202101:56:54AM 45 ). Analogousfindingsfor 38 , 176 et al. 39 34 46 www.eje-online.org :2 ). ). Specifically, ). Furthermore, demonstrating 40 ). Maternal 42 R81 , 43 41 via freeaccess ). ), European Journal of Endocrinology www.eje-online.org reproductive disorders. oxidative statehasbeenlinked withmetabolicand mitochondria. Incessantpropagation ofthispostprandial stress originatesfromtwomajor sources:leukocytesand consumption andcookingmethods. Postprandialoxidative of calorieintake,typemicronutrients,antioxidantnutrient which ismodulatedviadifferent co-existingfactors:amount Food ingestioninducesoxidativestress,themagnitudeof Figure 3 factors ( and mitochondria,canbemodulatedbyseveralcoexisting formation andgeneration,originatingfromleukocytes supply of antioxidant nutrients ( consequence ofexcessoxidativeloadorinadequate the pro-oxidantloadandantioxidantdefenseasa describe thepostprandialstateofimbalancebetween postprandial oxidativestress–hasbeenintroducedto p47 proteinsIKK the expressionofinhibitory I changesweredetected,withadecreasein inflammatory κ B Review α phox Im Therefore, a new term – dietary ornutritional Therefore, anewterm–dietary andanincreaseinNF- pair Leukocytes subunit( Metabolic and Fig. 3 ed secr Postprandial oxidativestr ). etio Infla 3. re Mitochondria-independent: n sponse 47 In 1. mma inflam cr 2. ). Intracellula eased ROSpr accu

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lipid consumptionevokesequaloxidativeresponses oxidative stress.Asmentionedabove,carbohydrateand is also catalyticin the amplitude of postprandial carbonylation( in ROSgenerationbyleukocytes,lipidperoxidationand in whichcaloricrestrictionledtoarespectabledecrease affected bythecaloricamount,asindicatedstudies from mitochondria,ROSgenerationbyleukocytesisalso superoxide anionsenterthecirculation ( to molecularoxygen.Asaresult,moreand eventually leadingtoincreasedtransferofsingleelectrons capacity of mitochondria for oxidative phosphorylation, concentrations ofglucoseandFFA outpacethetotal free fattyacids(FFA) inbloodcirculation. Theseample in abnormalsurges in blood glucose, triglycerides and stress. Excessiveamountofhigh-caloriefoodresults affecting theintensityofpostprandialoxidative ROS generationinthepostprandial state.Therefore, presence of obesity or physical inactivity, can also affect increase inLDLsusceptibility tooxidation( meal-induced oxidative stress and mitigate the postprandial against atherosclerosisandCVD,wasalsoshowntoprevent red wine,whichisestablishedtohaveaprotectiveeffect geneexpression( proinflammatory total inhibitionofROSgenerationandadecrease in a stressinnormal subjects,with and inflammatory meal wasshowntopreventthemeal-inducedoxidative when combinedwithahigh-fat,high-carbohydrate postprandial state.Forexample,orangejuiceintake nutrients canalsoinfluencetheoxidativemilieuin concentration ofNF- resulted inamoreavidactivationofMNCsandincreased of highglycemicindexcarbohydratesbyhealthysubjects were reportedintermsofglycemicindex,asconsumption carbohydrates, differencesinpostprandialoxidativestress feeding scenario( oradetrimentaleffectofSFA inanacute PUFA-rich mealsonpostprandialplasmainflammatory to proveclearbeneficialeffectoftheconsumption However, and have failed scientific dataare contradictory effect( are knowntoexertananti-inflammatory linked toCVD,whereasn-3polyunsaturatedfats(PUFA) inflammation, assaturatedfats(SFA) havebeenclosely consumed mayhavearoleintheimmediatepostprandial a moreprolongedone.Regardinglipids,thetypeoffat by leukocytes,exceptforthefactthatlatterevokes Nutrition andoxidativestress Furthermore, thetypeofmicronutrientsconsumed The amountofcaloricintakeisadecisivefactor Lifestyle characteristicsof an individual,suchas Consumption ofantioxidantandanti-inflammatory 55 κ B ( , 50 Downloaded fromBioscientifica.com at09/26/202101:56:54AM 57 56 , 51 ). ). Simultaneously, regarding , 52 ). 58 ). In a similar setting, ). Inasimilarsetting, 176 10 :2 59 , 48 , 60 , 49 , 53 61 ). Apart R82 , ). 54 via freeaccess ). European Journal of Endocrinology cycle ( oxidative stress and ultimately initiate an endless vicious tissues interactingwithnutrients willfurtheraggravate pancreatic tissues includingadiposetissue, skeletalmuscle,liverand orchestrates adominoofmetabolicchangesindifferent stress, aftercarbohydrate,lipidandproteinintake, metabolic statusofthetissues.Postprandialoxidative oxidative responseatthecellularlevelaltering and Nutrient ingestiontriggersamajorinflammatory tissues level Nutrition andoxidativestress atthemetabolic disorders inwomenaswell. to thepathophysiologyofmetabolicandreproductive state thatcharacterizesmodernlifestylemaycontribute these derangementsduringthecontinuouspostprandial factors invariousdiseases.Incessantaccumulationofall are slowlygainingimportantattentionasmajorrisk hyperlipidemia, orso-calledpostprandialdysmetabolism, postprandial state.Indeed,hyperglycemiaand and oxidative derangements in the major inflammatory body ofevidenceindicatingthatnutritioninduces BMI changes( improvement oftheirhormonalprofile,independent of alipaseinhibitor(orlistat)ledtorespectable AGE dietinconjunctionwith6-monthadministration our group in womenwithPCOS,itwasshownthatlow- on reproductivedisturbedwomen,aswell.Inastudyby subjects ( flow-mediated dilatationbothinhealthyanddiabetic dysfunction, as depicted by asignificant decreasein AGEs (coke)resultedpostprandiallyinacuteendothelial Uribarri AGEs( temperature leadtoformationofdietary high inproteinandfat,cookedshortlyunder impact onoxidativemetabolismpostprandially. Foods, postprandial oxidativestress( failed todisplayabeneficialeffectoftrainingstatusinthe endogenous antioxidantdefenses,variousresearches have exercise isconsideredasapowerfultoolofupregulating its effectinpostprandialoxidativestress.Although dataprevailintheliteratureconcerning contradictory non-obese healthyindividuals( stress inresponsetoahigh-fatmealcomparisonwith experience anexaggeratedandmorepersistentoxidative as depictedinastudybyBloomer Review Taken alltheaboveintoaccount,thereisalarge Finally, cookingmethodscanalsohaveanaggravating Fig. 4 t al et 66 β ). Dietary AGEsseemtohaveanegativeimpact ). Dietary ). -cells. These active but metabolically disturbed . showedthatasingleoralchallengeby 67 ). 63 , and others E Diamanti-Kandarakis 62 64 ). Regardingexercise, , t al. et 65 ). , obesesubjects

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). ). box proteinO1,IL-6:Interleukin6,MCP-1:Monocyte tissues level(ER:endoplasmicreticulum,FoxO1:Forkhead Nutrition asmediatorofoxidativestressatthemetabolic Figure 4 ETC: electrontransportchain). chemoattractant protein-1,TLR4:Toll-like receptor4, impact onnutrientutilization postprandially( oxidative statusthatmaypossibly haveanunfavorable suggesting thatobesityis accompanied byanaltered tissue ofobesepatientscompared withleancontrols, expression wasfoundtobe higherinthewhiteadipose NOS (iNOS)areabundantinadipocytesandtheir to ROSgeneration.EndothelialNOS(eNOS)andinducible Additionally, NOSappearstobeasignificant contributor of non-mitochondrialsources ofROSinadipocytes( stimulated ROSgenerationunderlyingtheimportance in 3T3-L1adipocytesinhibitspalmitate-andglucose- such asglucoseorpalmitate( in fatcellsexposedtoexcessnutrientderivatives, of the enzyme expressed in adipocytes and is increased oxidase. NADPHoxidase4(NOX4)isthemajorisoform promote ROSproductioninadipocytes,suchasNADPH substrate overload( cells, ROS may derive from mitochondria and ETC adipocytes arenotconsideredpureenergy-producing sources ofintracellularROS inadipocytes.First,although players inadiposetissuefunction( to themetabolicbalanceofhumanbody( role intheinsulin-mediatedglucoseuptake,contributing multiple metabolicandhormonalactionswithacentral Adipose tissueisasanactiveendocrineorganwith Adipose tissue Nutrition andoxidativestress Oxidative metabolismandROSproductionaremajor 70 ). Inaddition,variousenzymescan Downloaded fromBioscientifica.com at09/26/202101:56:54AM 71 69 ). SilencingofNOX4 ). Therearedifferent 176 www.eje-online.org :2 68 73 ).

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72 via freeaccess ). ). European Journal of Endocrinology www.eje-online.org three different groups of normal-weight, overweight and three differentgroupsofnormal-weight,overweight al et tissue ( signalinginvisceraladipose activation ofinflammatory fed withhigh-fatmealdisplayedanacutepostprandial first shown in a rat model by Magne response takesplaceintheadiposetissue( in adiposetissue( status that couldinterfere intheroleof free radicals oxidative stresscouldpossibly leadtoanadverselocal tissue ofobesemice( intheadipose of antioxidativeenzymeswas observed expression ofNADPHoxidaseanddecreased increased ROSproductionaccompaniedbyaugmented by Furokawa led toadysregulatedsecretionofadipokines,asshown stress, viaNADPHoxidaseactivation,andoxidativestress adipocytes, elevated FFA resulted in increased oxidative postprandially intheadiposetissue.Incultured and secretionofvariouscytokines( promotes macrophageaccumulationintheadiposetissue mediated viatheToll-like receptor(TLR-4),whichfurther The effectsofFFAs pathwaysare oninflammatory in adiposetissuethroughthereleaseofexcessiveFFAs. ingestion, ahigh-fatdietmayinducelocalinflammation pathwaysbynutrient direct activationofinflammatory and thequantityoffatconsumed( adipose tissue inflammation, independent of the quality metabolic syndromeexhibitanexacerbatedpostprandial a studybyMeneses tissue compared with a saturated fat diet ( responsein adipose attenuated postprandial inflammatory consumption ofadiethighinmonounsaturatedfatledto metabolic syndrome demonstrated that long-term On onehand,theLIPGENEstudyof75subjectswith different scientificgroups,butdataremaincontradictory. responseinadiposetissuewasaddressedby inflammatory fatalterspostprandial quality andquantityofdietary of adiposity( detected withinadiposetissue,independentofthedegree obese subjects, a similar increase in IL-6 and MCP-1 was promotes lipidsynthesisandinhibitslipolysis( of GLUTtransportersandglucoseuptake,additionally insulin-signaling cascade,asitenhancestranslocation adipocytes ( have highlightedthat insulin may elicit H physiological roleinitsmetabolicfunction.Earlyreports Review Finally, oxidativestresscanalsobe detected Following consumption of a meal, an inflammatory ROS inadiposetissueseemtohaveapotential ., 6 78

h aftertheconsumptionofamixedmealby ). Similarly, in as shown by Travers 74 ). ThistransientH t al et 79 ). Furthermore,whetherthespecific 84 ., What’s more,inthesamestudy, ). 83 t al et ). Therefore,thenutrition-induced . showedthatindividualswith 2 and others E Diamanti-Kandarakis O 2 82 productionamplifies 81 ). ). Apartfromthe t al et 2 O 2 production in 77 ., where rats 80 ). Thiswas ), whereas 75 , 76 ).

disrupt skeletalmuscleinsulin signalingandpromote insulin-signaling interference ( leading tofurtherexacerbation ofoxidativestressand pathway, increasingDAGsynthesisviaPKC activation pathway, AGEs formation, hexosamine biosynthesis through multiplemetabolicpathways,includingpolyol inhibition istheaugmentedfluxofglucosemetabolites dehydrogenase (GADPH)( sensitive glycolyticenzymeglyceraldehyde3-phosphate This excessROSpromotestheinhibitionofredox- increased superoxideformationandoxidativestress( Krebs cycle andETC capacity, ultimately leading to glycolytic fluxandglucoseoxidation,whichoverwhelms ofglucoseresultsinaugmented muscle. Increasedentry glucose andFFAs, accumulateintracellularlyinskeletal ample concentrationsofenergysubstrates,suchas as aconsequenceofhigh-fatmeal,oroverfeeding, to switch fromlipidtocarbohydrate use (‘metabolic conditions isknownasmetabolicflexibility. Inability uptake, oxidation and storageunder insulin-stimulated suppression oflipidoxidationandincreasedglucose of fattyaciduptakerduringfastingconditionstothe from predominantlylipidoxidationandhighrates availability. Thecapacityofskeletalmuscletoswitch pathways, asfuelutilizationshouldbeadjustedto ( uptake inskeletalmuscleviaGLUT4transporters energy homeostasis. roleinis fullofmitochondriathatexertaregulatory ( and representsacardinalsource ofenergyproduction of postprandial insulin-stimulated glucose disposal of the metabolic circulation. It accounts for about 80% Skeletal musclecanbecharacterizedasatrafficcontroller Skeletal muscle flexibility tolipidandinduceinsulinresistance( muscle mitochondrialabnormalitiesinfluencemetabolic literature dataarecontradictory, itwasproposedthat flexibility ismitochondrialoxidativecapacity. Although ( tissue forlipidstorageandthestatusofphysicalactivity availability, plasmaFFA levels, the availabilityofadipose metabolic flexibilityofanorganism,includingnutrient insulin resistance( associated withintramyocellularlipidaccumulationand inobesepatientsandisinflexibility’) wasobserved Nutrition andoxidativestress 86 88 85 ). Thisisacriticalstepinthebody’s metabolic ). Another factor that may be implicated in metabolic ). Asapureenergy-producingorgan,skeletalmuscle Simultaneously, increasedplasmaFFA levels also When calorieintakeexceedsenergyexpenditure, After nutrientintake,insulinpromotesglucose 87 ). Various factorsdeterminethe Downloaded fromBioscientifica.com at09/26/202101:56:54AM 89 ). TheresultofGADPH 90 ). 176 :2 88 R84 ). 48 via freeaccess ). European Journal of Endocrinology levels intheliverpromote effect inlivermetabolism. IncreasedmalonylCoA intracellular lipidaccumulation thathaveadetrimental fatintake leadtoincreasedFFAdietary liver supplyand In a similar setting with skeletal muscle, overfeeding or Liver enzymes ( oxidative phosphorylation muscle ( further exacerbatethemetabolicdysfunctionofskeletal cycle isinitiatedasthesemitochondrialabnormalities and increasedROSformation.Asaresult,vicious synthesis, impairedmitochondrialgeneexpression mitochondrial dysfunction,withdecreasedATP fatseemstopromoteoverfeeding andincreaseddietary PGC-1 encoding forthemitochondrialbiogenesisregulators daysshoweddownregulationofgenes fat dietfor3 In anotherstudy, volunteersfedanisoenergetichigh- itself suppressesmitochondrialATP production( muscle biopsies,fattyacidmetabolitepalmitoylcarnitine healthy volunteers’mitochondriaisolatedfromskeletal on mitochondrialbiologyandfunction( processes inskeletalmusclethroughdirectalterations mediators ( subsequent systemic release of FFAs and inflammatory causesROSproduction,with protein foldingmachinery . IfUPRisprolonged,thepersistentoxidative protein foldinganddegradationofaberrantlypackaged protein response’(UPR),responsibleforERbiogenesis, ER stress, misfolded proteins activate the ‘unfolded associated with endoplasmic reticulum (ER) stress. During ( phosphorylation activation, which in turn inhibit insulin receptor the inhibitorof complex activation, which results in degradation of c-Jun NH( toll-like receptor (TLR-4) in skeletal muscle promoting pathways,saturatedfattyacidsactivate inflammatory pathways ( turn impairsignalingofinsulin-stimulatedintracellular lipid metabolitesareactivesignalingmolecules,whichin (DAG), triacylglycerol(TAG) andceramides( mainly as long-chain fatty acyl-CoA, diacylglycerol storage leadstoectopicfataccumulationinskeletalmuscle, with limitedadiposetissueabilityforfatuptakeand insulin resistance( Review Dietary habits can also affect physiological metabolicDietary α and-1 Fig. 5 2 93 97 )-terminal kinase(JNK)andI , , ). 94 98 β andforgenesencodingmitochondrial , κ ). 95 B (I 91 ). Furthermore,FFAs directly activate ). Excessfatintakeinconjunction κ Ba) andnuclearfactor- 96 de novo ). Finally, lipotoxicityisalso and others E Diamanti-Kandarakis fattyacidsynthesis κ 101 99 b kinase(IKK) ). Innormal ). Overall, 92 κ B (NF ). These 100

κ B) ). ). NO, MDA and PAI-1 ( levels ofoxidativeandprothromboticmarkers,suchas FFA-exposed cultured hepatocytes displayed increased ceramides ( pathways, leading to formation of TAG, DAG and mitochondria andaredivertedtootherbiosynthetic activity. Asaresult,fattyacidscannotbeoxidizedin and inhibitcarnitinepalmitoyltransferase-1(CPT-1) function, aspancreatic protein misfoldingandERstress,whichcanpromote heavy anabolicburdenthatconsequentlypromotes and massivesubstratesupplytoliverexposesERa addition, inanexperimentalmodelbySoardo insulin signaling,includingPKCandJNKpathways.In cascadesthatderegulate initiate variousinflammatory resistance ( hepatic insulinresistancemayprecedesystemic visceral orskeletalmusclefatcontent,suggestingthat lipid accumulationwithoutanysignificantincreasein 3-day high-fat feeding led to athree-fold increase of liver insulin mRNAandimpairment ofinsulinsignaling FFA levels ledtoadecreaseininsulingeneactivityand cells, exposuretohighconcentrations ofglucoseand cell function( in diabeticpatientshasdetrimentaleffectspancreatic in pancreaticcellsandaltersinsulinsecretion( through theabovementionedmechanisms,actsdirectly levels, chronicinflammationandinsulinresistance oxidative stress,inducedbyelevatedglucoseandFFA more sensitivetoROSadverseactions( levels (SOD,catalaseandglutathioneperoxidase) by Tiedge in mitochondriaandcytosol( decreased insulinmRNA,ATP andcalciumfluxreductions production ofp21cyclin-dependentkinaseinhibitorand β to oxidativestress.InanexperimentbyMaechier Oxidative stress can significantly compromise Pancreatic HDL-cholesterol clearance( VLDL triglyceridesecretioncombinedwithelevated and dyslipidemiacharacterizedbyelevatedhepatic mediated suppressionofhepaticglucoseproduction lipid accumulationresultsinimpairedinsulin- persistently activated( signalingactivationif ROS productionandinflammatory Nutrition andoxidativestress -cells exposedtohydrogenperoxideactivated the Chronic elevationofplasmaglucoseandFFA levels et al β 103 102 -cells ., 108 ). As we mentioned above, these lipids ). In a rat model by Samuel β -cells arelowerinantioxidantenzyme ). Inculturedcellsofislets orHIT 104 β 102 Downloaded fromBioscientifica.com at09/26/202101:56:54AM -cells areinnatelymoresensitive ). Simultaneously, overfeeding ). Finally, intrahepatocellular 105 106 ). ). Furthermore,asshown 176 www.eje-online.org :2 107 ). Therefore, t al et 6 ). ., only t al et R85 et al β -cell via freeaccess ., ., .,

European Journal of Endocrinology www.eje-online.org which furtherdeteriorate chronic low-gradeinflammation andAGEproduction, that furtherexacerbateoxidative stress( which inturnactivatesmultiple metabolicpathways β intracellular mitochondrialROSformationinpancreatic addition, hyperglycemia by itself can trigger increased the underlyingmechanismsofthesederangements. In stress andaberrantfreeradicalgenerationcanbeone of the glucose-stimulatedinsulinsecretion( disorders (redarrowup). accumulation andsubsequentlytoincreasedmetabolic antioxidant capacityleadingtoincreasedfat decreased estrogens;squareinred: dysfunction andmetabolicdisorders;redarrowdown: accumulation, insulinresistance,peroxidation,B-cell down: decreasedoxidativestressleadingtofat increased antioxidantcapacitythroughER green arrowup:increasedestrogenicactivity, greensquare: disorders inwomen.+ER Nutrition asamediatorofoxidativestressinmetabolic Figure 5 -cells, promotingalocaloxidativemicroenvironment, Review α : presenceofEstrogenreceptors- β -cell function( and others E Diamanti-Kandarakis α ; Greenarrow 108 110 109

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α ); ); sex hormonesandtheirimbalancehasbeenclearly mediators of oxidative stress in women, the role of diabetes mellitus( obesity, insulinresistance,metabolicsyndromeand rise tomultiplemetabolicdisordersinwomen,including is emerging asone of the principalparametersthatgive oxidative stress.Thenutrition-inducedstress stimulate multipleintracellularpathwaysandpropagate saturatedfattyacidsandglycotoxins well asdietary hypernutrition, high-fat,high-carbohydratemeals,as intracellular events in the major metabolic organs.Chronic Nutrition and calorieintake initiates aplethoraof metabolic disorders inwomen Nutrition asamediatorofoxidativestress in reproductive disorders stress infemalemetabolicand Nutrition asamediatorofoxidative antioxidant response( ROS formation,activates PCG1aandinducesan and mitochondrialbiogenesis, altersmitochondrial and mitochondrialreceptors promotesATP production oxidative stress( expenditure indirectly via mitochondrialfunctionand sensitive tissues,E2canregulatemetabolismandenergy β byprotectingand secretionenhancingisletsurvival and enhancelipidhomeostasis,insulinbiosynthesis Estrogen receptorsarealsopresentin pancreatic well asfailuretosuppressliverglucoseproduction( high-fat dietdisplayeddecreasedinsulinsensitivity, as In addition, liver-specific ER fat accumulationandactivationofstresskinases( metabolism was downregulated, inducing intracellular ( effect ininsulinsignalingandGLUT4expression muscle, estradiol(E2)receptor glucose homeostasis( pancreatic sensitive organs,includingskeletalmuscle,liverand not onlyinreproductivetissues,butalsoinsulin- metabolic function ( effects, theyareimportantregulatorsofbody’s to oxidativestress.Beyondtheirpurereproductive glucose homeostasis( demonstrated by their impact on insulin signaling and Nutrition andoxidativestress 114 -cell fromoxidativestressandapoptosis( In thepathogenesisofmetabolicdisordersand Apart fromthedirectactionsofestrogensoninsulin- Estrogens andtheirmetaboliteshavebeenlinked ). Inskeletalmuscleofovariectomizedmice,lipid β -cells, playing a modulatory roleininsulin– -cells, playingamodulatory 118 Fig. 5 ). Specifically, E2bindingtonuclear 111 112 119 ). Downloaded fromBioscientifica.com at09/26/202101:56:54AM 113 ). ). Their receptors are present , ). Analytically, inskeletal 120 α -knockout micefedwitha , 121 α (ER 176 ). Consequently, E2 α :2 ) hasapositive

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β R86 116 115 -cells via freeaccess ). ). ). European Journal of Endocrinology change intheirreproductive potential,directlyoriginating stress inmetabolicdysfunction. conclusions abouttherole of nutrition-relatedoxidative an importantconfoundingfactorindrawingdefinite metabolic derangements and can be established as clearly protectpremenopausalwomenfromdeveloping the metabolicandantioxidantpropertiesofestrogens of high-fatdiet( liver steatosisandinsulinresistanceafterconsumption mouse model, males had a higher propensity to developing and oxidativestressinadiposetissue( adiponectin andreductionsinimmunecellinfiltration more glucosetolerant,duetoincreasedexpression of weight-matched malemice.However, theyremained adiposity andenlargedadipocytesizecomparedwith obese maleandfemalemice.Femalesdisplayedgreater et al Furthermore, inanexperimentalmodelbyNickelson a lipid load inthe form ofheavy whipping cream ( with regardtoMDAandH as womenexperiencedloweroxidativestressthanmen, ( women displaysignificantlylowerlevelsofoxidativestress in comparisontohealthyyoungmen,premenopausal induced metabolicandoxidativederangements.First, focusing on gender-dependentdifferences in nutrition- oxidative balance. This is nicelydepicted in experiments abundance seem tofavorablyinfluencemetabolismand between noandrogensandexcessof( control butalsohowimportantistheroleofbalance androgen receptorsmayexertaprotectiveeffectinmetabolic after 8-weekhigh-fatdiet,highlightingthatnotonly fat, decreasedinsulinsensitivityandmarkeddyslipidemia knockout micedisplayedincreasedbodyweightand recent experimentalmodel,femaleandrogenreceptor- failure anddiabetesmellitus( and weresubsequentlypredisposedtopancreatic androgen excessexperiencedsystemicoxidativestress addition, inamousemodelbyLiu action and promote insulin resistance ( was shownthatandrogenexcess hyperandrorgenemia ispresent.InwomenwithPCOS,it syndrome(PCOS),where from womenwithpolycysticovary remains unclear. Themajorityofavailabledataoriginate human body. is highlightedasanatural,innateantioxidantagentof 127 Review During reproductiveage,hormonalstatusandE2 Regarding androgens,theirmetabolicroleinfemales Entering menopause,women experienceasevere ., high-fatdietwasadministeredtoweight-matched ). Analogousfindingswerereportedpostprandially, 130 ). Taken alltheaboveintoaccount, 2 O 125 2 levels,afteringestionof and others E Diamanti-Kandarakis per se ). However, inamore et al can impair insulin canimpairinsulin ., female mice with ., femalemicewith 122 129 , ). Inasimilar 123 126 , 124 ). β 128 ). In ). In -cell -cell

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of estrogendeficiency( from estrogen–androgenimbalancewithmajordefect ( acting asregulatorsofkeyantioxidantgeneexpression able topreventandcounteractsuchmodificationsby Simultaneously, hormonereplacementtherapyis DNA repairabilityandtotalantioxidantstatus( reduced PON1Aactivityandelevatedlipoperoxidation, even duringperimenopausalperiod,manifestedby ( body, mainlythroughadecreaseinantioxidantdefenses been showntoincreaselevelsofoxidativestressinthe cardiovascular events( resistance andmetabolicsyndrome,aswelladverse central adiposity, dyslipidemia,progression of insulin an abruptreductioninmetabolicrate,shifttoincreased signs. Lossoftheirmaincirculating estrogen,E2leadsto many tissuesandproducesavarietyofsymptoms replacement therapy(HRT) usecompared with control was reducedby62%inwomen withcurrenthormone population-based prospective cohortstudy, diabetesrisk insulin resistanceandmetabolic dysfunction.Ina also underlinedtheprotectiveeffectofestrogenagainst replacement therapy( comparison toovariectomizedmicereceivinghormone glucose tolerance and whole-body insulin resistance in mass, reducedwhole-bodyenergyexpenditure,impaired ovariectomized miceledtoincreasedbodyweightandfat Camporez improved thesederangements( resistance. Administration of soyisoflavones significantly oxidant markers,aswellglucoseintoleranceandinsulin blood antioxidantswithaconcomitant elevation of with high-fatdietshowedamarkedreductionofwhole in anotherexperimentalmodel,ovariectomizedratsfed females supplementedwithestradiol( in comparison with intact females or ovariectomized sucrose dietdisplayedhighersusceptibilitytoperoxidation, Busserolles metabolic imbalancewasalsoevaluated.Inastudyby background. Thepotentcontributionofnutritiontothis and estrogenreplacementwereusedtomimichormonal evaluated inanimalmodels,whereartificialmenopause oxidative dysfunctionduringmenopausewasextensively postmenopausal women( metabolic andendothelialdysfunctionthatcharacterizes characterizes postmenopausal women potentiates the Nutrition andoxidativestress 135 133 In addition,themarked reduction in estrogen has The unique role of estrogen deficiency in metabolic and , ). Women experienceincreasedoxidativestress 136 ). Consequently, thispro-oxidantstatethat et al et al . demonstratedthat4-weekhigh-fatdietin ., ovariectomizedfemaleratsfedwithhigh- 132 140 131 Downloaded fromBioscientifica.com at09/26/202101:56:54AM 132 ). ). Largeclinicalstudieshave ). Ovariansenescenceaffects , 137 ). 176 139 138 www.eje-online.org :2 ). Analogously, ). Furthermore, R87 134 via freeaccess ). European Journal of Endocrinology www.eje-online.org during embryonic development and implantation( during embryonic ( especially whenantioxidantdefensesareinsufficient spindle andincreasedriskforabnormalzygoteformation, oxidative stress before fertilization leads to disrupted meiotic protein(StAR)( regulatory mainly throughalteredproductionofsteroidogenicacute impaired cholesterol utilization andproteinsynthesis, women undergoing assisted reproductive techniques oxidative stressinfertility. Themajorityoftheminvolve conducted so farinorder to explore theputative role of in ordertosecurenormalovum functionanddevelopment. ofadelicateoxidative balance arecrucial and preservation oxidative equilibriumintheovarianmicroenvironment responseattheimplantation site ( secretory of cyclic GMP, which mediates estrogen-stimulated uterine contribute asananti-plateletagent,wellaregulator Although its function is not established, NO seems to overexposedtoH it hasbeenshownthatovary of femalereproductivesystem.Inovariansteroidogenesis, oxidative metabolismisalsoimplicatedinotherfunctions protein ATP production ( and antisteroidogenicactions,DNAdamageinhibited IIprogression,leadingtodiminishedgonadotropin evolution, whereasontheotherhand,ROSadverselyaffect follicleisanimportantpromoteroftheovulatory ovulatory suggesting thatcontrolledROSproductionbythepre- by anincreaseinROSandinhibitedantioxidants, follicleisinduced resumption ofmeiosisIaprimary maturation, asseenin environment duringdifferentstagesofphysiologicaloocyte play acomplexandmultifunctionalroleintheovarian of folliculogenesis.Freeradicalsandantioxidantsseemto Oxidative metabolismisacriticalintraovarianregulator reproductive disorders Nutrition asamediatorofoxidativestress infemale metabolic state. as hormonalfluctuationscanuniquelydetermineher woman isadecisivedenominatorinthisco-interaction, estrogens/with orwithoutandrogenexcess,ofevery However, thehormonalbackground,withorwithout development ofvariousmetabolicdisordersinwomen. oxidative stresscansignificantlycontributetothe sensitivity ( women with preexisting diabetes and increased insulin individuals ( 144 Review Consequently, a plethoraofstudieshavebeen Concluding, calorieintakeanditssubsequent ). Finally, role acritical,regulatory NOseemtocarry 142 141 ). ). HRTalsoimprovedglucosecontrolin Fig. 6 143 143 ). Apart from folliculogenesis, ). Apart from folliculogenesis, . For example, on one hand, . Forexample,ononehand, ). In addition, exposure to ). Inaddition,exposureto and others E Diamanti-Kandarakis 146 2 ). Overall, ). Overall, O 2 led to ledto 145

). ). potentially impairfertility, byalteringfollicularphysiology and itwasshownthatelevatedFFA concentrationscan cultured model by Valckx investigated, buttoamuchlesserextent.Inanexperimental local oxidativestressintheovarianmilieuhasalsobeen achieving pregnancyinthesewomen( plasma antioxidantstatuswasshowntobebeneficialin with successrates( (TAC) ofpatientsundergoingIVFwaspositivelyassociated other hand, follicular fluid total antioxidant capacity fertilization andpregnancyrates( quality,lower ovarianresponse,poorerembryo decreased fluid ofwomenundergoingARTwereassociatedwith MDA, ROS,NOandlipidperoxidation(LPO)infollicular pregnancy outcomes.Specifically, increasedlevelsof of oxidativestresswerecorrelatedwithfertilizationand (ART), wherevarioussystemicandfollicularfluidmarkers significantly correlatedwithconceptionrates( IVF, follicularfluidlevelsofsoluble form ofRAGE(sRAGE) outcomes ( levels werethemostsignificantpredictorsofpregnancy development. What’s more,lowerfollicularfluidAGE follicular growth,fertilizationratesandembryonic follicular fluidAGElevelsnegativelycorrelatedwith undergoing IVF, have documented that serum and ( potential roleofAGE-RAGEsysteminfemaleinfertility Recently, differentresearch groupshaveinvestigatedthe dysfunction( microenvironment andovulatory tissue, promotingsignificantperturbationsinovarian contributes toincreasedAGEdepositioninovarian inactivity withoxidative biomarkers in follicular fluid ( relationship betweentotalcalorieintake,BMIandphysical ( development and negativelyinfluenceembryonic rich diet can induce oxidative stress in oocyte environment undergoing assistedreproductionprogramrevealedthatfat- Analogously, study of 236 women an observational and reducingoocytedevelopmentalcompetence( delicate, marginal threshold distinguishing beneficial and in femalereproductive physiology ( can potentiallyleadtoinfertility. parameter in theinitiation of ovarian dysfunction, which Overall, intraovarianAGEaccumulationcanbeadecisive ( AMH, awell-knownmarkerofovarianreserve Finally, sRAGE seems to be positively correlated with Nutrition andoxidativestress 154 157 Finally, AGEconsumption increaseddietary The role of nutrition and its impact on inducing The roleofnutritionanditsimpactoninducing Concluding, oxidativemetabolism hasauniquerole ). However, Kazemi ). Jinno in vitro 158 t al et inthepresenceofFFAs untiltheantralstage ). Inanotherstudyofwomenundergoing et al ., in a retrospective analysis of women 150 ., early secondary murine follicles were murine follicles were ., early secondary , Downloaded fromBioscientifica.com at09/26/202101:56:54AM t al et 151 . failed to prove a potential . failedtoproveapotential ), whereasenhancedblood 147 176 , i. 6 Fig. 152 148 :2 ). , ). Thereisa 149 ). Onthe R88 160 159 156 155 153 via freeaccess ). ). ). ). ). European Journal of Endocrinology ovary syndrome). Reactive oxygenspecies,NO:nitricoxide,PCOS:polycystic manifestation ofvariousreproductivedisorders.(ROS: augment detrimentaleffects ofpro-oxidantsandmediatethe alters femalereproduction.Nutritionaloxidativestresscan between pro-oxidantsaffects intraovarianenvironmentand regulator infemalereproductivedisorders.Dysequilibrium Nutritional oxidativestress:animportantintraovarian Figure 6 depletion ofovarianfollicles andreducedabilityto far extensively characterized in terms of gradual Ovarian functionaldecline withaginghasbeenso Ovarian aging therapeutic target,arelimited. oxidative stressinfemalereproductivedysfunction,as a solid conclusionsabouttheroleofnutrition-promoted reproductive abnormalities( could beapotent,underlyingmechanismofvarious normal ovarianfunction.Therefore,oxidativestress tosecure pro-oxidant:antioxidant ratioismandatory harmful effects of oxidative stress and tightly controlled Review 5 ). However, dataestablishing and others E Diamanti-Kandarakis

levels decline( by excessiveROSgenerationcombinedwithantioxidant aging originatesfromacontinuousimbalance,derived development ( produce oocytes competent for fertilization and further observed in different ovarian compartments, including indifferentovariancompartments,including observed in oxidativelydamagedlipids,proteinsandDNAare mouse modelbyLim catalase downregulation( superoxide dismutase,Mndismutaseand also occurs in granulosa cells,accompanied by Cu/Zn With theweakeningofantioxidantdefense,aging of freeradicals,arereducedinoocyteswithage( glutathione ,whichareeffectiveintheremoval in premenopausalwomen( found to be higher in postmenopausal women than lipoproteins (ox-LDL),4-hydroxynenalandMDAwere cytokines andpro-oxidantbiomarkerssuchasoxidized in the ovary havenotbeenadequatelyevaluatedand in theovary the direct effects of nutrition-induced oxidative stress follicle shouldbeencouraged. Theroleofnutritionand mitochondrial dysfunction andROSoverloadinthe and furtherinvestigation of thenetworkinvolving oxidative stressinovarianagingareonlyindicatory found tobedecreasedinagedovariesofmice( powerful enzymaticsystemofAGEscavenging,wasalso the activityandexpressionofglyoxalase-1(GLO1), a and ultimatelytriggerovariandysfunction( of oxidative stress response through RAGE interaction, compromised efficiencyofvascularizationandactivation initiate adversemolecularintraovarianevents,such as across lifespanmay of thesecompoundsintheovary aging ( suggest apossiblecorrelationofAGEswithovarian follicles of premenopausal women,findingsthat andatretic intheprimordial,primary were observed cells ( in granulosathecainterna,endothelialandstromal beingpresent RAGE washighlyexpressedintheovary tissue obtainedfromreproductive-agedwomen,whereas demonstrated thatAGEsarepresentinnormalovarian the processof ovarian aging.A study by our group increase levelsofoxidativestressinthebody( as themarkedreductioninestrogen,havebeenshownto hormonal alterationsthataccompanyovarianaging,such alterations ofantioxidantenzymeexpression( granulosa cellsandovarianinterstitialtissue,alongwith Nutrition andoxidativestress Analytically, serum concentrations of inflammatory Overall, experimentaldataregardingtheroleof Furthermore, AGEsmayalsobeinvolvedin 168 169 ). Inaddition,increasedlevelsofpentosidine ). Consequently, potential accumulation 162 161 ). ). Oxidativestress-inducedovarian et al Downloaded fromBioscientifica.com at09/26/202101:56:54AM ., significant age-related increases ., significantage-relatedincreases 165 163 ). Similarly, asshownbya ). In contrast, GSH and ). Incontrast,GSHand 176 www.eje-online.org :2 170 166 167 171 ). Finally, ). Finally, ). ). R89 164 via freeaccess ). ). European Journal of Endocrinology www.eje-online.org PCOS ( has alsobeenhighlightedas anotherpotentmodulatorof net ofthesyndrome( environmental parameters,are allinvolvedintheinterplay conjunction withthepivotal contributionofgeneticand insulin resistanceandlow-gradeinflammation, in alterations,androgen excess, gonadotropin-secretory etiopathophysiological coreremainsvague;however, clinicalpractice ( encountered ineveryday common endocrinopathiesofpremenopausalwomen, syndrome(PCOS)is one ofthemost Polycystic ovary Polycystic ovarysyndrome stress infemaleinfertility. to investigatedeeperthefieldofdiet-inducedoxidative inorder examinations cantakeplace,aremandatory and biologicalsample interventions in which dietary future, prospective,well-designedpregnancystudies, of womenwithoutovarianstimulation.Therefore, hormones, creatingamilieuthatdiffersfromtheFF follicle maturationisstimulatedwithexogenous fluid compositioninwomenundergoingIVFwhere The majorityofthemhavefocusedonfollicular induced oxidativestressininfertilityarelimited. only withclomiphenecitrate( improve ovulationratesincomparisontowomentreated induction in women withunexplainedinfertility failed to was administratedwithclomiphenecitrateforovulation N and Polak idiopathic infertilitywerealsoreportedbyWang levels ofROSintheperitonealfluidwomenwith compared withfertilecontrols( peritoneal fluid of women with idiopathic infertility significantly contributestoitspathogenesis. remains unclear, it is believed that oxidative stress anovulation andspermdefects( known causesofinfertility, includingbutnotlimitedto tests have been performed on both partners to rule out oftimed,unprotected intercourse where after 12 months exclusion and is defined as the inability toconceive Idiopathic (unexplained) infertility is diagnosed by Unexplained infertility to reachmoredefiniteconclusions. warrant more experimental and clinical models, in order -acetyl cysteine(NAC),apotentantioxidantcompound, Review Human studiesregardingtheroleofnutrition- Total antioxidantstatuswasfoundtobelowerin 178 , t al et 179 . ( ). 172 , 176 173 , 177 ). However, astudyinwhich ). Recently, oxidative stress 174 5 and others E Diamanti-Kandarakis 172 ). Althoughitsetiology ). ), whereaselevated 175 ). Its t al et

. postprandial hyperglycemia,hasalsobeenstudied with PCOS( dismutase (SOD),whoseactivitywasenhancedinwomen activities were shown to be decreased, and superoxide such asparaoxonase-1(PON-1)andglutathione,whose detected intheconcentrationsofenzymaticantioxidants, PCOS ( free radicals,wasfoundtobedecreasedinwomenwith which represents the ability of human body to eliminate (TAC), an aggregative index of plasma antioxidant state, perpetuating oxidativestress.Total antioxidantcapacity theredoximbalanceand suffering fromPCOS,conserving levels ofantioxidantsalsoseemtobeaffectedinwomen to beelevatedinwomenwithPCOS( asymmetric dimethylarginine (ADMA) levels were shown Murri altered inPCOS.Specifically, inarecentmeta-analysisby accumulating datahighlight theroleofoxidativestress with PCOS, as well ( drive analogousdetrimental cellulareventsinwomen all thesepathophysiological processesandseemsto above, oxidative stress is a common denominator of and endothelialdysfunction( by obesity, abdominaladiposity, insulinresistance metabolic signaling, PCOS is commonly accompanied characterize womensufferingfromPCOS.Regarding both reproductive and metabolic dysfunctions that to oxidativestress,asstresscontributes to and metabolicabnormalitiescouldbeuniquelylinked glycemic dysregulationinwomenwithPCOS( impact onpancreatic hyperglycemia-induced inflammationhasanadverse sensitivity, it wasrecently shown by Malin with PCOS( markers even in lean women of various inflammatory and the concomitant upregulation of the expression to increasedsensitizationofleukocyteshyperglycemia predominates inPCOS,seemstosignificantlycontribute peroxidase (GPx)( action ofenzymaticantioxidants,suchasglutathione What’s more,hyperglycemiawasalsoshowntoalterthe and NF- markers (i.e., TNF-a stimulating secretion of inflammatory presence of obesity and abdominal adiposity, via in womensufferingfromPCOS,independentofthe monocytes in response to hyperglycemia was observed in PCOS.Specifically, increasedROSproductionby Nutrition andoxidativestress Nutrition-induced oxidativestress,through Various pro-oxidantbiomarkershavebeenshowntobe PCOS could serve asamodelinwhich reproductive PCOS couldserve et al. 181 κ B) andactivationofNADPHoxidase( , , ,(MDA)and 182 180 188 ), whereasvariousabnormalitieswerealso , , 183 189 187 , β ). Interestingly, apartfrominsulin 184 ), andhyperandrogenemia,which -cell function,furtherexacerbating Downloaded fromBioscientifica.com at09/26/202101:56:54AM 48 ). ). Regarding reproduction, 176 176 ). Asdiscussed 180 :2 ). Conversely, 190 t al et 185 , , . that 191 R90 186 via freeaccess ). ). European Journal of Endocrinology t al. et linked toinsulinresistance. InamousemodelbyCai dysfunction, itiswellestablished thatAGEsareclosely dysfunction in PCOS ( in granulosacellswithpotential interferenceinovarian signaling pathways,specificallywithinsulin Accumulating AGEsinterfere with intracellularovarian as well as NF- endothelial ovariancellsandhigherexpressionofRAGE increased AGEdepositionintheca,granulosaand against glycation( ovarian glyoxalase-1activity, aprotective enzyme in thecaandgranulosacells,aswelldownregulated rats displayedincreaseddepositionofAGEsandRAGE women withPCOS.Specifically, female high-AGE-fed follicular maturationprocess( indicating thepotentialroleofoxidativestressin AGE levelsinPCOSwomen,afindinghumanstudies these women( effects in both reproductive and metabolic function of obesity and insulin resistance, exerting unfavorable women withPCOS,independentofthepresence diet. AGEs were shown to be distinctively elevated in produced endogenouslyaswellderivingmostlyfrom withdominantpro-oxidantcapacity,inflammatory studies inPCOSwomen.AGEsareknowntobeextremely menopause inwomenwithPCOS( from humanstudiesdonotseemtoconfirmanearly ( washup ofovarianreserve PCOS mayinduceaccelerationofagingprocessandearly ovarian agingprocess.Notsurprisingly, itisimpliedthat and follicularfluid,derangementsthatalsoprevailin oxidative stresswerefoundtobealteredbothinserum byRezvanfar ovary hyperandrogenism-induced murine model of polycystic ( and were accompanied by poorer fertilization rates displayed thehighestlevelsofROSingranulosacells ( IVF populations ofinfertilewomenwhounderwent markers ofoxidativestresswereassessedindifferent 193 qualityanddecreasedpregnancyrates( embryo lower ratesofoocytematurationandfertilization,poor capacity (TAC), whichweredirectlyassociatedwith ROS andMDA,aswelldecreasedtotalantioxidant with PCOSdisplayedincreasedfollicularfluidlevelsof inPCOS.Womenin themicroenvironmentofovary 194 194 Review ). Infact,inastudybyKaruputhula AGEs haveadirectimpactontheovariancellsof Equally significantarethedataonAGEs,derivedfrom ). Finally, weshouldmentionarecentstudyof ). Amongthewholecohort,womenwithPCOS , itwasdemonstratedthat micefedwithahigh- κ 198 B p65subunit in granulosa cells ( ). Also,AMHcorrelatesstronglywith 200 t al. et , , inwhichvariousmarkersof 201 202 195 199 ). PCOovariesdisplayed ). Concerningmetabolic ). However, clinicaldata and others E Diamanti-Kandarakis ). 196 , 197 t al et ). ., various 146 , 168 192

). ). , (GR), vitamins A,C,E,, zinc cadmium andreducedlevels ofTAC, SOD,catalase, GPx, increased concentrationof ROS,NO,LPO,,lead, those withthedisease( reported increasedlevelsof oxidativestressmarkersin circulation ofpatientswithendometriosis,othershave increased oxidative stress in the peritoneal fluid or in bibliography. Althoughsomestudiesfailed toobserve stress inendometriosis.Dataaremainlycontradictory investigating theroleofnutrition-relatedoxidative abnormalities inwomenwithPCOS. process inreproductiveaswellmetabolic rest etiologicalparameters,orchestrates thepathogenetic evident thatoxidativestress,inconjunctionwiththe inordertosetsolidknowledge,itbecomes is mandatory oxidative statusandviceversa.Althoughmoreresearch insulin resistance,bothofwhichareaggravatorsthe PCOS, asthesewomendisplayhyperandrogenemiaand etiology ofmetabolicandreproductiveaberrationsin improvement oftheirmetabolicprofile( and oxidativestressmarkers,depictingasignificant parallel decreaseinserumAGE,insulinlevels,HOMA-IR AGEintakeinwomenwithPCOSresulteda dietary analogous human model by Tantalaki mice fedwithanisocaloricAGE-freediet( adiposity andeventuallydiabetes,incomparisonwith AGE dietdemonstratedinsulinresistance,abdominal extent ofcelldeath( antioxidant defensesaredecisiveindeterminingthe release andapoptosis.Cellularoxidantproperty turn activatesmultiplesignalingpathways, place, leadingtoexcessiveproductionofROSthatin toxic compounds,autoxidationofhemoglobintakes cavity. Asfreehemeandironareconsideredgenerally derivatives toendometrioticlesionsorperitoneal the pro-oxidanthemoglobintransfershemeandiron , oneofwhichisoxidativestress( been postulated regarding the pathophysiology of been associatedwithinfertility. Various theorieshave affects 6–10% ofwomenreproductive age andhas tractoreveninlungs.Endometriosis viscera, urinary outside theuterus,mostofteninovaries,abdominal unknown etiology, inwhichendometrialtissueispresent Endometriosis is a benign gynecologic disorder of Endometriosis Nutrition andoxidativestress A plethoraofscientificstudieshavefocusedon After bleedingandhemolysisinendometriosis, Oxidative stress holdsa respectable share inthe 205 5 ). InarecentstudybySingh Downloaded fromBioscientifica.com at09/26/202101:56:54AM ). 176 www.eje-online.org :2 204 t al et ). 203 5 ., lower ). ). Inan R91 et al via freeaccess ., European Journal of Endocrinology www.eje-online.org acids orpolyunsaturatedfatty acidsandpolyphenols, months,enrichedinmonounsaturated fatty diet for3 Ceriello in healthyindividuals( and bodycoretemperature (twomarkersoflongevity) stress anddecreasedsignificantlyfastinginsulinlevels example, 6-monthcaloricrestrictionattenuatedoxidative oxidative balance and promoting cell longevity. For patterns canexerttheexactlyoppositeeffect,securing to ovariandysfunction( protective enzymeagainstglycation,ultimatelyleading the cellularmilieuanddownregulatingglyoxalase-1, a altering AGEs andRAGEinovariantissueswasobserved, in femalehigh-AGE-fedmice,increaseddeposition of ( can potentiallyleadtotissueinjury actionsofAGEsthat depicted thepotentinflammatory increase inserumTNF-a,CRPandVCAM-1levels fed for6 weeks indiabeticpatientsresultedasignificant variety ofdiseases. status,which,inturn,canpredisposetoa inflammatory are repeated,theyimposeasustainedoxidativeand physiological functions. When these derangements an acutesettingcanmodifyintracellularandextracellular milieuin Nutrition-induced oxidativeandinflammatory oxidative homeostasis Long-term effects ofnutritionin possible linksandconclusions. not correlated with clinicaloutcomes, in order to reach were enhanced( and antioxidantmarkers,specificallySODGPx, and lipidhydroperoxides,weresignificantlyattenuated peripheral oxidative stress markers, including MDA diet wasadministeredinwomenwithendometriosis, a studybyMier-Cabrera endometriosis, incomparisonwithcontrols( redox systemweredetectedininfertilewomenwith vitamin Clevelsandimbalancedintrafollicularthiol- lower plasmaSODconcentration,follicularfluid in womensufferingfromendometriosis.Specifically, endogenous antioxidantcompoundsarealsodisrupted and VEGF),MCP-1ox-LDL( (IL-6, TNF-alphaandIL-beta),angiogenicfactors(IL-8 cytokines concentrations ofMDA,proinflammatory of thesepatientshasalsobeenfoundtocontainhigh undergoing IVF( inwomenwithendometriosis and seleniumwasobserved Review On theotherhand,restrictedcalorienutritional In astudybyVlassara et al ., diabeticpatientsfollowing aMediterranean 149 209 ). Analogously, theperitonealfluid ). However, datawere laboratory 200 210 et al et al , ). Inaddition,inastudyby 201 ., whenahigh-antioxidant ., inwhichhigh-AGEdiet ). and others E Diamanti-Kandarakis

19 206 ). Simultaneously, ). Furthermore, 207 , 208 ). In

stress modulatesandinterferesdirectlyindirectly milieu. Specifically inwomen,nutritional oxidative pathways ofvariousorgans,unfavorablyalterthecellular clustering ofmolecularchangesinthemainsignaling accompanying postprandialoxidativestressinitiatea oxidative stressinhumanbody. Nutrientintakeandits Nutrition constitutesoneofthemajormodulators Conclusion the occurrenceofvariousdiseasesinwomen. detrimental pathophysiologicalpathwaysandpromote divergences caneasilyviolatethiscellularbalance,initiate both inanacuteandachronicsetting.Nutritional catalytically inthemaintenanceofoxidativebalance controls ( improved basalendothelialfunction,incomparisonwith displayed increased plasma antioxidant capacity and References the public,commercialornot-for-profit sector. This researchdidnotreceiveanyspecificgrantfromfundingagencyin Funding perceived asprejudicingtheimpartialityofthisreview. The authorsdeclarethatthereisnoconflictofinterestcouldbe Declaration ofinterest into accountasarecurrentlyconsideredcontributors. the qualityandtimingofmealsshouldalsobetaken of foodquantityremainsthemostwell-studiedfactor, but disorders, modificationofnutritionalhabitsbyreduction Therefore, in women with metabolic and reproductive targeted therapeutic modalitiesachallenging field. pathophysiological linksarestillescaping,making are ultimatelycompromised.Nevertheless,theexact with themetabolicandreproductivefunctions,which Nutrition andoxidativestress 1 5 4 3 2

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) Accepted 27September2016 Revised versionreceived20September2016 Received 24July2016 210 209 208 207 206 211 Nutrition andoxidativestress

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